Skip to main content

Advertisement

SpringerLink
Log in

Operating on Jehovah’s Witnesses: A Challenging Surgical Issue

  • Original Paper
  • Published:
Journal of Religion and Health Aims and scope Submit manuscript

Abstract

Blood transfusion is often utilized in surgery. Greece is the second-highest consumer of blood components in Europe. It has been shown that at least half of all transfusions are unnecessary and could be avoided. Jehovah’s Witnesses (JWs) are a Christian religion that do not accept transfusion of whole blood or the four primary components of blood—namely, red blood cells, white blood cells, platelets, and plasma. This a retrospective study from September of 2015 to January of 2018, analyzing all JWs who underwent an elective operation at the Second Department of Propaedeutic Surgery in Laiko University Hospital. Twenty-nine (Rogers et al. in NCCN Guidelines Version 2.2014 Cancer- and Chemotherapy-Induced Anemia. NCCN Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network, Fort Washington, 2013) JW patients, 23 females (74.1%) and eight males, were operated on during the aforementioned period. The median ASA score was 1 (range 1–3), and only two of the patients needed postoperative monitoring in the ICU. Almost half of the patients (45.1%) needed iron infusion and EPO injection preoperatively. Two patients presented with postoperative complications, with no postoperative deaths. In conclusion, we found that surgery, in our small group of JW patients, was safe and successful despite the lack of blood transfusion. Techniques developed to treat JW patients should be more widely used to improve clinical outcomes and reduce costs to the healthcare system.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • (2012). Watch Tower Bible and Tract Society of Pennsylvania: Religious and Ethical Position 1/16.

  • (2016). Recommendations from the College of Intensive Care Medicine and the Australian and New Zealand Intensive Care Society on end-of-life care, invasive devices, anaemia, sedation and antibiotics. Accessed 31 March 2017.

  • Section 47 of Greek Law No. 2071/1992

  • Achneck, H. E., Sileshi, B., Jamiolkowski, R. M., Albala, D. M., Shapiro, M. L., & Lawson, J. H. (2010). A comprehensive review of topical hemostatic agents: efficacy and recommendations for use. Annals of Surgery, 251(2), 217–228.

    Article  PubMed  Google Scholar 

  • Agarwal, A., Begum, S., Chudasama, M., & Raidullah, E. (2013). Elderly patients with severe anemia refusing blood transfusion: case studies and review of literature. Journal of Asian Scientific Research, 3(12), 1173–1180.

    Google Scholar 

  • Alexander, J., & Cifu, A. S. (2016). Transfusion of red blood cells. JAMA, 316(19), 2038–2039.

    Article  PubMed  Google Scholar 

  • American Society of Anesthesiologists Task Force on Perioperative Blood Management. (2015). Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology, 122(2), 241–275.

    Article  Google Scholar 

  • Chaney, M. A., Jellish, W. S., & Leonetti, J. P. (1996). Perioperative management of a Jehovah’s Witness presenting for skull base surgery. Skull Base Surgery, 6(2), 133–136.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Chaudhry, N., & Dharmarajan, T.S. (2010). Severe anemia in the older Jehovah’s Witness: an experience with two contrasting cases. The New York Medical Journal, 5(2).

  • Convention of Oviedo Article 9, Code of Medical Ethics L. 3418/2005 Article 29 par. 2, Legal opinion of Ms. Eirini Kyriakakis “Patient refusal of medical procedures and the physician’s duty to treat. The example of refusing blood transfusion for religious reasons” par. 5.6 Human Rights, issue 69/2016

  • Dicpinigaitis, P. V. (2010). Optimization of tissue oxygenation in critically ill Jehovah’s Witness patients. American Journal of Medicine, 123(8), e17.

    Article  PubMed  Google Scholar 

  • Dixon, J. L., & Smalley, M. G. (1981). Jehovah’s Witnesses: the surgical/ethical challenge. JAMA, 246, 2471–2472.

    Article  CAS  PubMed  Google Scholar 

  • Ferraris, V. A., Davenport, D. L., Saha, S. P., Austin, P. C., & Zwischenberger, J. B. (2012). Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Archives of Surgery, 147(1), 49–55.

    Article  PubMed  Google Scholar 

  • Franchini, M., Marano, G., Mengoli, C., Pupella, S., Vaglio, S., Muñoz, M., et al. (2017). Red blood cell transfusion policy: a critical literature review. Blood Transfusion., 15(4), 307–317.

    PubMed  PubMed Central  Google Scholar 

  • Frank, S. M., Wick, E. C., Dezern, A. E., Ness, P. M., Wasey, J. O., Pippa, A. C., et al. (2014). Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion, 54(10 Pt 2), 2668–2677.

    Article  PubMed  PubMed Central  Google Scholar 

  • Goodnough, L. T., Maggio, P., Hadhazy, E., Shieh, L., Hernandez-Boussard, T., Khari, P., et al. (2014). Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion, 54(10 Pt 2), 2753–2759.

    Article  PubMed  Google Scholar 

  • Graffeo, C., & Dishong, W. (2013). Severe blood loss anemia in a Jehovah’s Witness treated with adjunctive hyperbaric oxygen therapy. The American Journal of Emergency Medicine, 31(4), 756.e3–4.

    Article  Google Scholar 

  • Hallet, J., Tsang, M., Cheng, E. S., Habashi, R., Kulyk, I., Hanna, S. S., et al. (2015). The impact of perioperative red blood cell transfusions on long-term outcomes after hepatectomy for colorectal liver metastases. Annals of Surgery and Oncology, 22(12), 4038–4045.

    Article  Google Scholar 

  • Hashem, B., & Dillard, T. A. (2004). A 44-year-old Jehovah’s Witness with life-threatening anemia from uterine bleeding. Chest, 125(3), 1151–1154.

    Article  PubMed  Google Scholar 

  • Jabbour, N., Gagandeep, S., Mateo, R., Sher, L., Strum, E., & Donovan, J. (2004). Live donor liver transplantation without blood products: strategies developed for Jehovah’s Witnesses offer broad application. Annals of Surgery, 240(2), 350–357.

    Article  PubMed  PubMed Central  Google Scholar 

  • Klein, M.J., Carter, T.I., Smith, M.C., Wong, J., & Sugiyama, G. (2014). Prophylactic hypothermia and neuromuscular blockade to limit myocardial oxygen demand in a critically anemic Jehovah's Witness after emergency surgery. Journal of Surgery Case Report, 2014(12).

  • Lawson, T., & Ralph, C. (2015). Perioperative Jehovah’s Witnesses: a review. British Journal of Anaesthesia, 115(5), 676–687.

    Article  CAS  PubMed  Google Scholar 

  • Leahy, M. F., Hofmann, A., Towler, S., Trentino, K. M., Burrows, S. A., Swain, S. G., et al. (2017). Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion, 57(6), 1347–1358.

    Article  PubMed  Google Scholar 

  • Lin, E. S., Kaye, A. D., & Baluch, A. R. (2012). Preanesthetic assessment of the Jehovah’s Witness patient. Ochsner Journal, 12, 61–69.

    PubMed  PubMed Central  Google Scholar 

  • Livraghi, A., Martinasso, A., Seghatchian, J., & Perotti, C. (2018). Creation of a new hospital service for iron therapy. Transfusion and Apheresis Science, 57(2), 282–284.

    Article  PubMed  Google Scholar 

  • Mackenzie, C. F., Morrison, C., Jaberi, M., Genuit, T., Katamuluwa, S., & Rodriguez, A. (2008). Management of hemorrhagic shock when blood is not an option. Journal of Clinical Anesthesia, 20(7), 538–541.

    Article  PubMed  Google Scholar 

  • Marinakis, S., Van der Linden, P., Tortora, R., Massaut, J., Pierrakos, C., & Wauthy, P. (2016). Outcomes from cardiac surgery in Jehovah’s Witness patients: experience over twenty-one years. Journal of Cardiothoracic Surgery, 11(1), 67.

    Article  PubMed  PubMed Central  Google Scholar 

  • Meybohm, P., Choorapoikayil, S., Wessels, A., Herrmann, E., Zacharowski, K., & Spahn, D. R. (2016). Washed cell salvage in surgical patients: a review and meta-analysis of prospective randomized trials under PRISMA. Medicine., 95(31), e4490.

    Article  PubMed  PubMed Central  Google Scholar 

  • Meybohm, P., Richards, T., Isbister, J., Hofmann, A., Shander, A., Goodnough, L. T., et al. (2017). Patient blood management bundles to facilitate implementation. Transfusion Medicine Reviews, 31(1), 62–71.

    Article  PubMed  Google Scholar 

  • Muñoz, M., Acheson, A. G., Auerbach, M., Besser, M., Habler, O., Kehlet, H., et al. (2017). International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia, 72(2), 233–247.

    Article  PubMed  Google Scholar 

  • Pattakos, G., Koch, C. G., Brizzio, M. E., Batizy, L. H., Sabik, J. F., Blackstone, E. H., et al. (2012). Outcome of patients who refuse transfusion after cardiac surgery: a natural experiment with severe blood conservation. Archives of Internal Medicine, 172(15), 1154–1160.

    Article  PubMed  Google Scholar 

  • Qian, F., Osler, T. M., Eaton, M. P., Dick, A. W., Hohmann, S. F., Lustik, S. J., et al. (2013). Variation of blood transfusion in patients undergoing major noncardiac surgery. Annals of Surgery, 257(2), 266–278.

    Article  PubMed  Google Scholar 

  • Remmers, P. A., & Speer, A. J. (2006). Clinical strategies in the medical care of Jehovah’s Witnesses. American Journal of Medicine, 119(12), 1013–1018.

    Article  PubMed  Google Scholar 

  • Rogers, G.M., Gela, D., Cleeland, C., et al. (2013). NCCN Guidelines Version 2.2014 Cancer- and Chemotherapy-Induced Anemia. NCCN Clinical Practice Guidelines in Oncology. Fort Washington: National Comprehensive Cancer Network.

  • National Clinical Guideline Centre. (2012). Acute upper gastrointestinal bleeding. (Evidence update August 2014. A summary of selected new evidence relevant to NICE clinical guideline 141. Evidence Update 63) London: Royal College of Physicians.

  • Schälte, G., Janz, H., Busse, J., Jovanovic, V., Rossaint, R., & Kuhlen, R. (2005). Life-threatening postoperative blood loss in a Jehovah’s Witness, treated with high-dose erythropoietin. British Journal of Anaesthesia, 94(4), 442–444.

    Article  PubMed  Google Scholar 

  • Shander, A., Fink, A., Javidroozi, M., Erhard, J., Farmer, S.L., Corwin, H., et al.; for the International Consensus Conference on Transfusion Outcomes Group. (2011) Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Transfusion Medicine Reviews, 25(3), 232–46.e53.

  • Shander, A., Van Aken, H., Colomina, M. J., Gombotz, H., Hofmann, A., Krauspe, R., et al. (2012). Patient blood management in Europe. British Journal of Anaesthesia, 109(1), 55–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Smilowitz, N. R., Oberweis, B. S., Nukala, S., Rosenberg, A., Zhao, S., Xu, J., et al. (2016). Association between anemia, bleeding, and transfusion with long-term mortality following noncardiac surgery. American Journal of Medicine, 129(3), 315–23.e2.

    Article  PubMed  Google Scholar 

  • Smoller, B. R., & Kruskall, M. S. (1986). Phlebotomy for diagnostic laboratory tests in adults Pattern of use and effect on transfusion requirements. New England Journal of Medicine, 314(19), 1233–1235.

    Article  CAS  PubMed  Google Scholar 

  • Solem, J. O., & Vagianos, C. (1988). Peroperative blood salvage. Acta Anaesthesiologica Scandinavica, 32(suppl 89), 71–75.

    Article  Google Scholar 

  • Spahn, D. R., & Goodnough, L. T. (2013). Alternatives to blood transfusion. Lancet, 381(9880), 1855–1865.

    Article  PubMed  Google Scholar 

  • Sun, Z., Honar, H., Sessler, D. I., Dalton, J. E., Yang, D., Panjasawatwong, K., et al. (2015). Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air. Anesthesiology, 122(2), 276–285.

    Article  PubMed  Google Scholar 

  • The National Institute for Health and Care Excellence. (2015). Blood transfusion NICE guideline [NG24]. https://www.nice.org.uk/guidance/ng24/resources/blood-transfusion-1837331897029. Accessed 31 March 2017.

  • The Royal College of Surgeons of England. (2016). Caring for patients who refuse blood: a guide to good practice for the surgical management of Jehovah’s Witnesses and other patients who decline transfusion. London: The Royal College of Surgeons of England. https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/caring-for-patients-who-refuse-blood/ Accessed 7 June 2018

  • European Commission. (2017). Building national programmes of Patient Blood Management (PBM) in the EU: a guide for health authorities. Brussels: European Union, pp. 9, 14. [ISBN 978-92-9200-717-1]. https://ec.europa.eu/health/blood_tissues_organs/publications_en. Accessed 6 June 2018.

  • Valsami, S., Grouzi, E., Pouliakis, A., Fountoulaki-Paparisos, L., Kyriakou, E., Gavalaki, M., et al. (2017). (2017) Red blood cell transfusions in Greece: results of a survey of red blood cell use in 2013. The Turkish Journal of Hematology, 34(1), 52–58.

    Article  PubMed  Google Scholar 

  • Vaziri, K., Roland, J. C., Robinson, L. L., Reines, D., & Fakhry, S. M. (2009). Extreme anemia in an injured Jehovah’s Witness: a test of our understanding of the physiology of severe anemia and the threshold for blood transfusion. Journal of Trauma, 67(1), E11–E13.

    PubMed  Google Scholar 

  • Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C., et al. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine, 368(1), 11–21.

    Article  CAS  PubMed  Google Scholar 

  • Wehry, J., Agle, S., Philips, P., Cannon, R., Scoggins, C. R., Puffer, L., et al. (2015). Restrictive blood transfusion protocol in malignant upper gastrointestinal and pancreatic resections patients reduces blood transfusions with no increase in patient morbidity. American Journal of Surgery, 210(6), 1197–1204.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Second Department of Propaedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece

    Zoe Garoufalia, Apostolos Aggelis, Efstathios A. Antoniou, Gregory Kouraklis & Costantine Vagianos

  2. Second Department of Propaedeutic Surgery, “Laiko” General Hospital, 17 AgiouThoma Street, 11527, Athens, Greece

    Zoe Garoufalia

Authors
  1. Zoe Garoufalia
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Apostolos Aggelis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Efstathios A. Antoniou
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gregory Kouraklis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Costantine Vagianos
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

ZG and AA collected and analyzed the data. EA and GK helped with the manuscript. CV navigated the whole project.

Corresponding author

Correspondence to Zoe Garoufalia.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Garoufalia, Z., Aggelis, A., Antoniou, E.A. et al. Operating on Jehovah’s Witnesses: A Challenging Surgical Issue. J Relig Health 61, 2447–2457 (2022). https://doi.org/10.1007/s10943-020-01175-5

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10943-020-01175-5

Keywords

Search

Navigation